Do No Harm by Henry Marsh

People who tend to be squeamish or prefer not to know about the internal workings of the human body, wouldn’t enjoy reading Do No Harm by Henry Marsh. It’s also probably best to avoid this book if you have a friend or relative who has been diagnosed with a neurological condition or is about to have surgery.

Marsh is a neurological surgeon with more than 30 years experience. In Do No Harm he offers insight into the joy and despair of a career dedicated to one of the most complex systems in the body. This is a candid account of how it feels to drill into someone’s skull, navigate through a myriad of nerves that control memory, reason, speech and imagination and suck out abnormal growths. If successful he can save someone’s life or extend their projected life span. But often he is millimetres away from catastrophe. One false move and the result could be death or paralysis.

Marsh frankly admits that in his career he has made mistakes. A few years ago, he prepared a lecture called “All My Worst Mistakes.” For months, he lay awake in the mornings, remembering the patients he had failed. “The more I thought about the past,” he recalls , “the more mistakes rose to the surface, like poisonous methane stirred up from a stagnant pond.”

On a visit to a nursing home for people with extensive brain damage he sees the result of some of those mistakes in the motionless forms of patients in their beds “To my dismay I recognised at least five of the names.” One of them is a schoolteacher in his fifties whose life he ‘wrecked’ (Marsh’s word) during a fifteen hour operation to remove a large tumour. In the final stages he tore part of the artery that keeps the brainstem, and thus the rest of the brain alive. The patient remained in a coma for the rest of his life. The experience haunted Marsh for years.

Yet without mistakes, he says, there would be no progress. And without the willingness of doctors to take risks, many of the greatest advances in his field would never have happened.

It’s one of the painful truths about neurosurgery that you only get good at doing the really difficult cases if you get lots of practice but act means making lots of mistakes at first and leaving a trail of injured patients behind you. I suspect that you’ve got to be a bit of a psychopath to carry on…

Does that mean surgery is always the best course? This is a question discussed regularly in the daily case conferences Marsh holds with the junior doctors and radiographers who form his hospital team. Is it kinder to let someone die gradually than to undertake invasive surgery from which they may never recover or if they do, face life changing side effects? The team reach a clinical, unemotional conclusion but its down to Marsh to face the patient and explain the decision. It’s an encounter that requires a delicate balance of compassion and detachment.

Marsh suffers anxiety before such meetings, trying to resist the temptation to be overly optimistic about the likely outcome of any procedure. Often before surgery he is oppressed by “almost a feeling of doom’ and panic which only dissipates at the last moment when he sits in his operating chair and takes up his scalpel.

… full of surgical self-confidence, I press it precisely through the patients scalp. As the blood rises from the wound the thrill of the chase takes over and I feel in control of what is happening.

Marsh never set out to become a neurosurgeon. After completing his medical degree he caught a glimpse through a porthole of a patient “anaesthetized, her head completely shaven, sitting bolt upright on a special operating table.” The surgeon stood behind her, with a light fixed to his head, patting her bare scalp with dark brown iodine antiseptic. The image stayed in his mind, and struck him as “a scene from a horror film.”

But his second visit to a neurological theatre fascinated him. Unlike all the other operations he had witnessed which involved the handling of ‘warm and slippery body parts’, this was done with an operating microscope through a small opening in the side of the head using only a few microscopic instruments.

The brain continues to fascinate Marsh. He is awed by what he sees through his surgical microscope, which “leans out over the patient’s head like an inquisitive, thoughtful crane ” as the infra-red cameras in his GPS system shows he position of his instruments. The internal cerebral veins are like “the great arches of a cathedral roof” and beyond the Great Vein of Galen can be seen “dark blue and glittering in the light of the microscope.”

In Do No Harm he does a grand job of sharing that wonder with his readers and also the drama of the operating theatre. You don’t need extensive biological or medical knowledge to appreciate the level of difficulty involved in these procedures though a schematic showing what bits of the brain lie where would have been a useful addition to the book.

Every chapter is headed with the name of a type of tumour (who knew there were so many?) in which Marsh talks about some of the cases that involved those conditions. In between he shares his many battles with the bureaucracies and inefficiencies he encounters in the British National Health Service (NHS).

Surgeons kept waiting because of a decree that doctors can’t begin a new operation while another is in the final stages in an adjoining theatre. Or theatre staff forced to kick their heels because their next patient wasn’t allowed to change into their hospital gown while there were members of another gender in the same waiting room. The working hours of junior doctors changed without any consultation with the surgical leads. Computer systems that won’t co-operate when a bed is needed quickly. The causes of Marsh’s frustration range far and wide.

In one episode, which would be farcical in any other sector, he describes having to leave his clinic to repeatedly go up two flights of stairs to get a password so he can discuss an X-Ray result with his patient. “Try Mr Johnston’s,” he’s told. “That usually works. He hates computers. The password is ‘Fuck Off 45’.” It marks the forty-five months since the introduction of a highly-expensive computer system.

Back in his office, Marsh tries every possible combination of upper and lower case letters, adding spaces, taking them out, all without success. He runs up the two flights again. One staff member realises there’s been a miscalculation. The system has been in place two months longer than they recalled. So it turns out the password is now “Fuck Off 47.” All of this while the poor patient waits to hear if Marsh can save his life by operating to remove the cause of his elliptic fits.

His railings stem from a deep concern for his patients and a desire to want to do right by them (he even washes and dries the hair of his female patients before they leave the theatre). He tries not to let his feelings show but his mask slips regularly. Leaving the hospital one evening having told one man that an operation was not possible, he rails against the traffic as if it were the drivers’ fault

“ … that this good and noble man should die and leave his wife a widow and his young children fatherless. I shouted and cried and stupidly hit the steering wheel with my fists. And I felt shame, not at my failure to save his life — his treatment had been as good as it could be — but at my loss of professional detachment and what felt like the vulgarity of my distress compared to his composure and his family’s suffering, to which I could only bear impotent witness.

This is a book that I never expected to enjoy but it proved far more readable than I expected. I’m glad however that I didn’t read it before my friend had her own surgery to remove a brain tumour (from which she thankfully recovered). I appreciated there were risks involved, but never realised just how narrow the margin of error would be. Sometimes ignorance is a blessing.

Footnotes

About the Book: Do No Harm by Henry Marsh was published by Weidenfeld and Nicholson in 2014.  It was shortlisted for the Costa Biography Award, the Wellcome Book Prize and the Guardian First Book Prize. Marsh wrote a follow up in 2017. Admissions  was written as he prepared for his retirement.

About the Author: Henry Marsh worked as consultant neurosurgeon in London for about thirty years. In addition he travelled regularly to the Ukraine, donating his time to treat patients in extremely difficult situations and in the face of political opposition. H retired from full time work in the NHS in 2015 but continued to work in private practice until 2017.

Why I read this book: This was a book club choice. I probably wouldn’t have read the book otherwise. But I am so glad I did.